tobacco dependence clinic facilitator’s guide · tdc facilitator's manual, april 2011 3...

Tobacco Dependence Clinic

Facilitator’s Guide

Compiled by:

Lindsay Killam MSW, RSW

Addiction Counsellor

Vancouver Coastal Health

in partnership with Health Canada

TDC facilitator's manual, April 2011 2

Table of Contents Introduction 3

Week 1: Balancing Your Decision 4 Group Guidelines 5

Facts About NRT 6

Decisional Balance 7

Tips for Getting Started 8

Smoking Tally Worksheet 10

Week 2: Know Your Triggers 11 Types of Triggers 12

Coping Strategies 13

Making a Coping Plan 14

Personal Coping Worksheet 15

Week 3: Starting to Plan 16 Review of Smoking Patterns 17

Scheduling Change 17

PHALT Chart 19

Week 4: Coping with Withdrawal 21 Effects of Withdrawal 23

Benefits of Quitting 25

Week 5: Managing Our Emotions – Stress 27 What is balance? 28

Understanding Stress 29

Tools for Managing Stress 30

Personal Stress Management Plan 31

Week 6: Healthy Living 33 Relationship between Diet and Smoking 34

Physical Activity 36

Week 7: Staying Positive and Supported 37 Understanding Self-talk 38

Personal Bill of Rights 39

Social Support 40

Week 8: Staying Quit/Relapse Prevention 42 Understanding a Slip and a Relapse 43

Relapse Prevention Plan 44

Appendix: Meditation and Visualizations 45

References 47


Introduction

This manual evolved out of three years of feedback from program participants, the

feedback and expertise of colleagues, and research in the field of smoking cessation. The

8-week program is based on the transtheoretical model of change. It focuses on moving

people from contemplation to action and provides the tools for maintaining change. The

weeks can be broken down into three subsections: developing awareness, making a plan,

and sustaining change.

Weeks 1-2 focus on ‘buy in’. Individuals are encouraged to notice their smoking, get

started on NRT (nicotine replacement therapy), identify triggers, and start practising

basic coping skills.

Weeks 3-4 focus on a practical plan for quitting. It is emphasized that quitting is a

process and that each person will have a unique plan. Quit dates are encouraged but

optional. Withdrawal is discussed in detail.

Weeks 5-8 focus on maintenance. Although many clients will not yet have quit, most

will have significantly cut down at this point. We know that when cigarettes are removed

people notice emotional, psychological, and physical voids in their lives. These weeks

provide information and practical skills to fill those voids with positive actions, positive

energy, and motivation. Relapse prevention is included at this stage.

Acknowledgements

A special thanks to Vancouver Coastal Health, Health Canada, the UBC research team,

and staff of VCH Tobacco Dependence Clinics for making this program and manual

possible.

Thank-you to the hundreds of participants who have courageously and successfully taken

on the challenge of quitting.

For further information about this manual contact: [email protected]


Week 1: Balancing Your Decision

Purpose: to engage the group in a conversation about their decision to quit, to

acknowledge and validate their historical reasons for smoking, to recognize their fears

about quitting, and to get them started in the process.

Opening round:

· Introduce yourself and other professionals involved with the program

· Suggest a round of names and how each person is feeling about starting the

process

Exercises to complete:

· Group guidelines

· Review expectations of program participation and the process of change (client’s

have detailed information about the ‘stages of change’ as additional reading in

their manuals)

· Review facts about NRT

· Decisional balance brainstorm

· Tips for getting started

· Introduce daily smoking tally for homework

Closing round:

· Ask clients to share one smoking reduction goal for the week (this may be actual

cigarette reduction, or something related to quitting such as working on the

smoking tally)


Exercise 1: Group guidelines

Ask clients to think about their best group experience and what they liked about it or if

they haven’t had a positive group experience, to think about their worst time in group and

what they would have liked to be different.

Write answers on a flipchart, answers should include:

• Confidentiality

• Cell phones off

• Be on time

• No cross-talk, no interrupting

• Respect (acknowledge that everyone’s quitting process will be different)

• Quitting is a process and not an event

• Guidelines are up for review throughout the 8 weeks

After the brainstorm take a moment to explain the expectations of participation in the

program. Points to include:

• Breaks are short but if one has to smoke they can go outside and away from the

entrance to the building

• Group support and NRT is available for up to 26 weeks. Attendance for the 8-week

group is mandatory; attendance at aftercare is up to each individual. In aftercare, NRT

is only provided if a client continues to attend group on a regular basis.

• Everyone’s process is individual; some people quit right away while others take several

weeks. Stick to what works for you and be open to learning from others. Remember:

there will be good weeks and bad weeks, ups and downs. Quitting is a process!!

Participants have additional information about change in their manuals.

• Do not compare treatment plans. Everyone’s choice of NRT is based on consultation

with the medical team. Let staff know if you are struggling with your NRT and we will

work with you to resolve the issue

• NRT will be given out in one-to-one sessions with a nurse or physician after each group

• Each week the group will receive handouts. Some of the information will be covered

during the session and additional information and worksheets will be available for

optional homework or journaling.


Facts about Nicotine Replacement Therapy (NRT)

Briefly review this information with the group and inform them that they can ask for

details in their one-to-one time with the doctor or nurse.

Nicotine replacement therapy constitutes the patch, gum, inhalers, and lozenges. Other

options for quitting smoking include prescription medications such as Champix and

Bupropion (Zyban).

Many people avoid NRT due to myths about its complications or effectiveness. The

reality is that NRT is a highly effective tool for managing the physical effects of

withdrawal. When we relieve discomfort it can help keep us motivated to change the

behaviours associated with smoking.

Common Myths:

Nicotine causes cancer. Nicotine is the addictive ingredient in cigarettes. Carbon

monoxide and carcinogens are harmful, along with 60 known cancer causing chemicals

in cigarettes.

21 mg patch is the highest treatment. Off label use of the patch is an option to increase

levels of nicotine and reduce discomfort of withdrawal. Patches can also be combined

with gum, lozenges, or inhalers. With medical consultation Zyban or Champix can also

be combined with NRT.

Wearing the patch and smoking will cause a heart attack. Wearing the patch and

smoking will not cause a heart attack. If this were to occur it is most likely due to years

of smoking, poor diet or unhealthy lifestyle.

Patch: • can be used in 3 steps and in off label dosages • can cause nightmares or sleep disruption • can cause mild irritation of the skin. This is from the adhesive and not the nicotine. • can fall off in hot weather • patch provides a level dose of nicotine over a 24 hour period

Gum and Lozenges: • delivers nicotine via tissue in the mouth • park-and-chew method of use • common side effect is upset stomach usually caused by improper use.

Inhaler: • small tube • nicotine is inhaled and absorbed through the mouth and throat • side effects are often a bad taste, burning sensation or throat irritation, upset stomach


Zyban: • pill form of medication • available by prescription • does not contain nicotine

Champix: • pill form of medication • does not contain nicotine. Reduces craving and pleasurable effects of nicotine • common side effects nausea, diarrhoea, abnormal dreams adapted from: CAMH TEACH Project

http://www.teachproject.ca\publicdownloads\SOR_Booklet.pdf (2011)

Exercise 2: Decisional Balance

Divide a flipchart into 2 sections and invite the group to brainstorm:

• What were\are your reasons for smoking? (do this first) • Why do you want to stop/What are your reasons for quitting?

Reasons for Smoking Reasons for Quitting

When the brainstorm is complete take a moment to emphasize that smoking had served a

purpose (ie. To spend time with friends, to take a break etc) but that they are all in group

because something has changed. **Stress usually comes up as a reason for smoking. It

can be interesting to inform the group that while smoking can provide an emotional time

out, it does not actually reduce stress. In fact, it increases physical stress on our

bodies.**

Make note if they were able to come up with responses for quitting with more ease than

the reasons for smoking. Also make note if the list for quitting is longer than the list for

smoking.

Follow up the brainstorm with the question:

• What are you most concerned about when you think of quitting?

Acknowledge that people usually have many fears about change. These fears stem from

the unknown. Sometimes they also stem from stories of failure told by others or from

past failed attempts. In this program we recognize that quitting is a process, everyone

will be different. While we encourage you to get down to 0 cigarettes you will be able to

decide your own timeline. There will be ups and downs, good weeks and bad weeks. It

is all learning that will help every person to move forward and to build up the toolbox of

resources that will bring success.

http://www.teachproject.ca/


Most people in the room will have had several decades of practice at being a smoker.

Reinforce with the group that learning to be a non-smoker takes time.

Exercise 3: Tips for Getting Started

Tell clients to open their manuals to the ‘tips for quitting section’

Tip 1: Think positive!! People feel more successful when they focus on what is going right

instead of all of the things they may feel that they are giving up.

Tell clients to review the list in their manual and add their own reasons. Encourage the

clients to post this list somewhere in their house where they will see it daily. They may

also want to write down their top reason on a recipe card and keep it in their wallet for

quick access (handout cards or cut paper for this activity).

Some examples of reasons to quit: (read with the group)

• I will be getting healthier

• I will have more energy and better focus

• My sense of smell and taste will be better

• I will have whiter teeth and fresher breath

• I will cough less and breathe better in the long run

• I will lower my risk of cancer, heart attacks, strokes, early death, cataracts, and skin

wrinkling

• I will be proud of myself

• I will feel more in control of my life

• I will no longer expose others to my second hand smoke

• I will have more money to spend/save

• I won’t have to worry about when I will be able to have my next smoke

After providing a few minutes to tick off their reasons and complete their little card, do a

quick round where each person shares their top reason.

Tip 2: Ask clients to think about what they would like support to look like.

Encourage them to think about past experiences of change to identify their needs.

• Tell people that your moods might be different for awhile but that it will pass

• Is there anyone who you want to invite to quit with you?

• Do you need to tell people to not talk about it with you or do you want everyone to

know and ask you how you are?


• Do you need to inform your doctor about this change, are you taking any medications

that a doctor should be aware of to be able to support you?

• Register for QuitNow either by phone or online (quitnow.ca)

Additional Exercises: Keep Track of When and Why You Smoke

Part of planning for quitting and success in staying quit is understanding one’s

relationship with smoking. Many people believe that they light up without thinking about

it. However, most cigarettes are attached to situations and/or feelings.

Review the following information with the group and encourage them to start exploring

their triggers over the next week.

Know your triggers:

Triggers can be moods, feelings, places or things you do. The following list identifies

some common triggers that smokers experience. Suggest that the group use this list as a

starting point to identifying their personal triggers. Tick off the ones that fit for them.

___Feeling stressed.

___Feeling down

___Talking on the phone

___Watching TV

___Driving a car

___Finishing a meal

___Playing cards

___Taking a work break

___Being with other smokers

___Drinking coffee

___Seeing someone else smoke

___Cooling off after a fight

___Feeling lonely

___After having sex

Other triggers:

_________________________________________

_________________________________________

_________________________________________

_________________________________________


Tracking Triggers for Smoking – Doing a Smoking Tally

Several tally sheets are available in the participant workbook. Ask clients to use this tool

to track their smoking. Encourage them to try at least one or two days of this type of

journaling. This tool will be valuable in identifying their personal triggers and to help

develop alternative coping in the future.

Cigarette

#

Time Situation (what are you

doing?)

Feeling

1 7:45am with coffee tired

Adapted from: Quit Now http://www.quitnow.ca (2010)

http://www.quitnow.ca/


Week 2: Know Your Triggers

Purpose: to support clients in noticing their daily triggers and to facilitate learning new

coping skills.

Opening round:

• How has the process been over the past week • Inform the group that you will be introducing relaxation exercise next week and that

participation will be optional


• Brainstorm individual triggers and discuss types of triggers (ie. Physical, emotional,

etc.) • Discuss coping strategies • Do a trigger/coping plan using the avoid/alter/acceptance strategy • Offer a personal coping worksheet for optional homework

Closing round:

• Have clients name one smoking reduction goal for the week


Exercise 1: Brainstorm Triggers

Brainstorm: Using a flipchart to record responses, ask clients to reflect on their

smoking tally from the past week or simply to reflect on their life experience, and name

some triggers.

When the brainstorm is complete make note of some of the different types of triggers that

people might experience such as physical triggers, emotional triggers, triggers associated

with situations or events, and thinking or cognitive triggers.

Some examples:

Physical triggers

· Our body’s physical response to withdrawal, dropping nicotine levels result in a

craving to smoke

Emotional triggers

· Sadness

· Stress

· Anger

· Worry

· Etc

Situations or Events

· Family get togethers

· Meeting friends

· Places ie. Bus stop, coffee shops, bars, parks

· Sun tanning

· Enjoying sports

· Watching TV

· Places or people that you have associations of smoking with – nostalgia

· Reward

· Breaks at work or school

Thinking or cognitive triggers

· “I can’t get through this without a smoke”

· “I need a break”

· “A smoke will ease my stress”

· “I deserve a smoke”

Explain that people experience triggers in diverse ways and therefore, our coping

responses need to reflect similar diversity.


Exercise 2: Learning to Cope with Triggers

Because triggers vary depending on the circumstance, our choice or options for managing

a trigger might also vary. We can use behavioural tools, cognitive strategies, or

emotional supports. Have the group open their manuals and discuss some of the tools

they could use.

Behavioural Tools – things that you DO to cope

· Leave the situation

· Avoid people, places, or things

· Take a walk

· Read a book

· Talk to someone

· Journal

· Meditate

· Sleep

· Have a drink of water

· Chew on something – gum, healthy food

· Choose NRT

· Keep your hands busy – knit, play cards, write

· Take a shower

· Listen to music

Cognitive Strategies – things that you THINK to feel better

· Remind yourself of why you are quitting

· Remind yourself that you don’t want to start over again

· Think about how you have coped (successfully) in the past

· Remind yourself that smoking won’t solve any problems

· Imagine how your health is improving

· Imagine riding the wave instead of being wiped out by it

· Tell yourself that smoking is not an option

Emotional Support – things you can do to FEEL better

· Practise breathing exercises

· Use grounding techniques

· Try to use containment – ie. Focus on one thought or emotion at a time

· Allow yourself to cry

· Reach out for support

· Distract yourself until the trigger/craving passes

· Do an activity that lifts your mood


Inform the group that it doesn’t matter which tools are used as long as they work.

Remind clients to avoid the temptation towards negative self-talk or beating themselves

up when they struggle. People who tend to see themselves as weak, stupid, or hopeless

tend to start smoking again.

Inform the group that initially they may experience many triggers as every new situation

or stress may evoke urges. Over time these urges lose their strength and while there may

be memories of smoking most ex-smokers will no longer have a desire to smoke.

Exercise 3: Create your Trigger Coping Plan

Ask the group to open their manuals to their trigger planning worksheet. Explain that we

can choose different coping strategies depending on what the trigger is. The following

information identifies 3A’s: avoid, alter, and accept.

Avoid - avoiding a situation is one of the most effective ways to prevent being triggered.

This may mean avoiding certain situations or people for at least a period of time.

Alter - During the times that you cannot avoid a situation/feeling/thought, changing the

trigger might be helpful. For example you might want to replace your morning coffee

with juice, change your routine, turn off the TV, engage in new activities (chew gum, go

for a walk, knit, get support), or alter your thinking, “I don’t need a cigarette to get

through this.”

Acceptance – sometimes life simply happens and despite our best efforts we are best to

simply accept and move on. Accepting ‘what is’ does not necessarily make a craving

seem any less urgent. In these situations it is useful to have gum, inhaler, etc…. or some

other alternative activity that distracts from the urge to smoke. It can also be helpful to

draw on positive self-talk or cognitive coping skills to get through.

Provide the group with several minutes to fill in 2-4 of their own triggers on their chart

and come up with a plan for coping with it. Invite the group to reflect back on the coping

strategies that were discussed in the previous section. When the group has finished invite

the members to share one of their triggers and what they plan to do to cope in the future.

Alternatively, this exercise can be done as a brainstorm with a few minutes afterwards to

fill in individual plans.

Example of a plan:

Trigger Avoid/Alter/Acceptance

smoking with coffee

limit coffee intake for the day, make home

smoke free and only have coffee inside,

have tea instead


Trigger Avoid/Alter/Acceptance

smoking at AA meetings attend non-smoking meetings, stay inside

during breaks, use gum or inhalers instead

stress deep breathing, talk to a friend, finish

tasks, acceptance

Encourage the group to use their worksheet as an ongoing tool to remind them of what

they thought would work or what has worked for them over time.

Adapted from: Canadian Mental Health Association (2005). Breathing Easy Workbook. Health Canada:

Canada.

Additional Exercise: Coping with Triggers, A Personal Plan

Point the group to this worksheet in their manual. Remind clients to think ahead and

prepare and they can get through the worst triggers. Clients can use this exercise to

further reflect on triggers and specific coping skills.

Instructions: try to think ahead about triggers (people, places, moods) that might cause

you to have urges to smoke. How many can you list? Write down what might cause you

to have an urge to smoke.

1. List 5 behavioural coping skills that you can use for these urges.

2. List 5 mental/cognitive skills that you can use for these urges.

3. List 5 emotional coping skills that you can use for these urges.

The Tobacco Research and Intervention Program at the H. Lee Moffitt Cancer Centre and Research

Institute at the University of South Florida. www.moffitt.org (2010)

http://www.moffitt.org/


Week 3: Starting to Plan

Purpose: to start to implement a strategy for reducing or quitting smoking over the

following five weeks.

Opening round:

• How has the process been going over the past week? • Depending on the feedback from the group this week can introduce basic meditation

and relaxation techniques. Explain that participation is optional. A good starting point

is to ask clients to close their eyes and simply focus on their breathing for a few

minutes (see appendix for optional meditations).


• do a review of information that individuals have noticed about their smoking patterns

over the past couple of weeks • plan for smoking reduction, lifestyle change, and rewards on a 2 month calendar • introduce the PHALT chart and encourage clients to read it through in detail as

homework

Closing round:

• Ask clients to name one smoking related goal for the week and one self-care plan for

the week


Exercise 1: Understanding your Smoking Pattern

The following exercise draws on the self-awareness about triggers that the group has

been working on over the past couple of weeks.

Ask clients to open their workbooks to this page. Offer a few minutes for individuals to

fill in their experiences. Bring it back to the group and invite participants to share some

of their observations.

Which days do you smoke the most?

What are you doing on those days?

Who are you with on those days?

Which days do you smoke the least?

What are you doing on those days?

Who are you with?

What time of day do you smoke the most?

What is your mood?

What are you doing?

Who are you with?

What time of day do you smoke the least?

What is your mood?

What are you doing?

Who are you with?

Remind the group that taking the time to understand their connections with smoking will

help them to successfully plan for change, as well as, sustain change.

Exercise 2: Planning Change on the Calendar

Part of achieving goals is to set out a plan that allows us to create our own benchmarks

for change. Ask the group to fill in a one month plan based on the following questions

(have these questions on a flip chart):

How do you plan to stop or reduce smoking?

Offer suggestions such as a quit date (optional), or weekly reductions


Inform the group that their plan is a guideline; it is common for the plan to change as they

start working on it. Some find that their smoking reductions go faster than planned, quit

dates often change.

List at least one lifestyle change that you would like to implement each week

Explain that quitting smoking is not about what we take out of our lives but also about

what we put in. As we reduce smoking we open up periods of time in the day to fill with

new, healthier activities. Offer suggestions (ask the group for their thoughts): cooking

healthy food, walks, exercise, spending time with friends, etc.

Plan one reward for yourself each week

We don’t have to be perfect to recognize hard work. Furthermore, we don’t always get

the recognition from others that we might hope for. Be your own biggest fan and do

something good for yourself. These may be: manicures, haircuts, a meal out, the movies,

saving money, opening a bank account, saving for a trip, getting teeth cleaned.

Rewarding our achievements helps us stay motivated through the ups and downs of

change.

After the group has had some time to work on their calendars, ask each person to share

about their reduction plan, one lifestyle goal, and one reward.

Following the sharing round do a quick brainstorm that acknowledges possible barriers

and solutions to successful change. The group has individual charts in their manuals to

follow along and document their own thoughts.

Barriers to Change Possible Solutions

CAMH TEACH Project:


Encourage clients to review their plan regularly, and continue to build on it through the

second month.



Sometimes it is also helpful to review some of the information and tools that lead to

success. You can refer to the page in their manuals that offers “Ideas to Help you in your

Process”.

Additional Exercise: PHALT Chart

The H.A.L.T. acronym is commonly used in 12-step programs. Adding the “P” includes

“Pain” as one of the risks for smokers to slip or relapse. Do a brief overview of it and

suggest that clients read it in detail at home.

P.H.A.L.T. CHART Post this P.H.A.L.T! chart on the refrigerator or desk. Sometimes we have a cigarette

only because we are really in Pain, Hungry, Angry, Lonely, or Tired.

Please be aware that self-awareness and self-care increase your chances of success!

P – PAIN AM I IN PAIN?

Experiencing emotional and/or physical pain can really tax our resources and put us at

risk for smoking to cope. Having tools to work through emotional pain and support is

necessary. Going to your doctor for regular medical care to solve health issues or get

support with pain management is important. Being able to know how to support one’s

self through pain and gain more support or skills when pain cannot be managed with

one’s current skill set is very important. If pain is unmanaged destructive coping skills,

like smoking, is often the result.

H - HUNGRY AM I HUNGRY?

Do I feel “something is missing?” When we get that feeling of emptiness, we often are

not able to decide whether we want food or cigarette- all we know is that we want

“something”. Smokers can miss a meal because they often don’t want to take the time to

eat – instead they just “smoke a meal”. If you have become a non-smoker, you can’t

afford to miss a meal- it is guaranteed to leave you feeling “hungry”. Although, your

BODY is calling for food, your ADDICTION is calling for nicotine. In the confusion,

you may relapse into thinking that ONLY a cigarette will fill in that “empty space”.

FILL YOUR STOMACH SO THE EMPTINESS WILL DIMINISH. YOU’RE TOO

VULNERABLE TO RELAPSE IF YOU DON’T PRACTICE WELLNESS BY EATING

SENSIBLY AND REGULARILY.

A - ANGRY/ FRUSTRATION INTOLERANCE


AM I ANGRY? DO I HAVE THE SKILLS TO MANAGE DAY TO DAY

FRUSTRATION?

Do I feel that my anger is a valid excuse to have a cigarette? Please remember that we

can still be worthwhile people when we are feeling angry- we don’t have to punish

ourselves with a cigarette. We don’t need to “stuff” down those angry feelings with a

cigarette! ANGER IS A VALID EMOTION. ANGER IS NOT A VALID EXCUSE

FOR HAVING A CIGARETTE!! FEELING angry is all right. What we DO with those

angry feelings may not be all right for you and others. Usually, we need to get in touch

with the angry feelings and admit to them- this self-awareness will begin to diminish the

angry feelings and reduce the anxiety of the unknown. Ask these questions:

“What am I afraid of losing?”

“What am I afraid of?”

CALL SOMEONE FOR HELP IF THE ANGER MIGHT LEAD YOU BACK TO

SMOKING!

L – LONELY/ BORED AM I LONELY? AM I BORED?

Feeling lonely can be overwhelming enough to send us back to smoking. Again, we need

to tell ourselves that FEELING lonely is all right, but what we DO with that lonely

feeling may not be all right for us and for others. Being alone does not need to be as

lonely if we can appreciate the person we are with- we need to like ourselves and realize

we are worthwhile even if we are alone. Some time boredom goes hand in hand with

loneliness. If we are under stimulated we can feel empty and need something to soothe

us. Isolating is a choice; using loneliness or boredom as an excuse to go back to smoking

is a choice. WE HAVE OTHER CHOICES!! Create new hobbies. Call a support person.

Become a volunteer. Give service. Get counselling or professional help.

IT TAKES STRENGTH TO ASK FOR HELP.

T - TIRED AM I TIRED?

All of us feel more vulnerable when we are tired. We begin the relapse process which

deludes us into thinking that the only way we will be re-energized is to “stoke our fires

with a cigarette.” If we don’t have time to sleep, we can always take a few minutes to do

a relaxation technique. People who are TRULY relaxed or centred have little need for

cigarettes!

PLEASE GET YOUR REST AND SLEEP. YOU ARE CERTAINLY WORTH IT!


Week 4: Coping with Withdrawal

Purpose: To inform clients about the signs and symptoms of withdrawal and support the

group in developing effective coping skills to manage withdrawal.

Opening round:

• How has the process been going over the past week? • Brief meditation


• Brainstorm with the group about their experience of withdrawal • Provide an overview of the effects of withdrawal and the benefits of quitting

Closing round:

• Name one smoking related goal for the week and one self-care goal


Exercise 1: Brainstorm Withdrawal

Most individuals in the group will have had previous quit attempts. For many, their quit

attempts have failed because of symptoms of withdrawal. For others, there may be a fear

of quitting because of the horror stories they have heard from friends and family about

withdrawal.

Introduce a brainstorm to the group that invites people to name and normalize their

worries and experiences. Ask: What symptoms of withdrawal do you believe you

have experienced in the past or what are you worried will happen as you quit?

When the brainstorm is complete use the information provided as an opportunity to talk

about the relationship between nicotine and the brain - physical addiction, as well as,

emotional connections with addiction.

Read with the group:

Physically, people crave cigarettes as a response to decreasing levels of nicotine in the

body. For many the discomfort of physical withdrawal can occur about 20 minutes after

the last cigarette. It can be faster or slower depending on the number the cigarettes per

day that the body is used to. When a cigarette is inhaled the nicotine reaches the brain

within 7 seconds. This releases dopamine into the pleasure/reward centres of the brain

and creates an artificially generated ‘feel good’ sensation.

Fortunately, the physical symptoms of addiction can be managed by nicotine replacement

therapy. Options such as the patch, release nicotine at continuous levels throughout the

day and therefore, alleviate the ups and downs of physical cravings from a smoking

pattern.

The emotional connection to cigarettes can sometimes be a greater challenge than the

physical addiction. Much like the theory of Pavlov’s dog, a smoker has been trained to

respond to a variety of emotional experiences by having a cigarette. There can be a belief

that the cigarette offers relief from uncomfortable emotions. Breaking this connection

can feel daunting and overwhelming but it is by no means impossible. Each time a

person chooses not to respond with a cigarette it starts to break these connections. It is

also important to remind ourselves that cravings average only 3 minutes before they pass.


Effects of Withdrawal:

Ask the group to open their manuals to the pages on the effects of withdrawal. Read

through it together.

Anger and Mood Swings:

Smoking creates a cycle of rising and falling nicotine levels. When that nicotine is cut

off it can feel like an emotional roller coaster. Emotions such as anger and anxiety are

common.

Time Perception Distortion:

For many, daily activity has been measured from cigarette to cigarette. Coping with the

withdrawal of nicotine can make time feel like it is dragging on. In reality, most craving

episodes last no more than about 3 minutes.

Inability to Concentrate:

Smoking nicotine pumps up the brain with adrenaline. It is why people sometimes feel

that they can skip a meal for a cigarette. Poor concentration can be associated with low

blood sugar.

Dizziness:

Your body has been suffering from a lack of oxygen for a long time. Dizziness should

subside after a couple of days.

Fatigue:

Nicotine is a powerful stimulant. Withdrawal and readjustment can be physically and

emotionally exhausting.

Trouble Sleeping:

Nicotine affects brainwave function. This can influence sleeping patterns and dreaming.

Tightness in Chest:

May be caused by the tension created in the body in its need for nicotine. As the body

starts to cleanse itself muscle stiffness is normal

Coughing, Mucous, Nasal Drip:


This is caused by the years of tar build up slowly loosening and being flushed from the

body.

Bad Breath:

This is caused by years of build-up of tar and other chemicals through the mouth, gums,

and lungs. Cell and tissue healing takes time.

Headaches:

Caused by increases in oxygen levels, tension, stress, and sleep disruption.

Constipation or Gas:

Intestinal or bowel movements can be disrupted in the period of quitting.

Depression or Sadness:

Quitting smoking marks the end of a dependent psychological bond. It can be felt as a

form of grief to let it go. Lack of sleep and tension may also contribute to a sense of

depression.

Loneliness or Feeling Cooped up:

There is a loss of routine or “sense of companion” that comes from quitting smoking.

Increased Appetite or Hunger:

This can be caused by hand-to-mouth habit, or replacement feeding for the now absent

nicotine induced adrenaline. The body craves more blood sugar.

Suicidal Ideation:

Quitting smoking can be very stressful, especially for individuals with vulnerable mental

health. Nicotine replacement therapy can have interactions with some psychiatric

medications. Many individuals also notice that letting go of cigarettes causes long-

stuffed emotions to surface and may not have the coping in place to deal with them. If

you find yourself depressed, psychotic, or thinking about ending your life, reach out to

your supports and consult with a physician as soon as possible.

Cravings:

It takes 72 hours of abstinence to purge our blood of nicotine. Cravings are more a

response to conditioning than to actual physical withdrawal. Cravings are the mind’s

way of warning us that it is time to ingest nicotine to avoid physical discomfort. For

most smokers the brain starts to send gentle reminders about every 20-30 minutes.

Unfortunately, even after all of the nicotine has left the body, the part of our mind that

generates cravings remains intact. When we feel a craving begin to escalate it is simply

the unconscious mind turning up the volume on what it has been conditioned to believe it

needs. Fortunately though, the average craving only lasts 3 minutes (it only seems like

longer). When the need is not fulfilled, the mind eventually quits prompting the desire.

Many cravings are triggered by the habit itself. Over time, smoking becomes associated

with different situations and feelings. It is necessary to recondition each trigger as it


arises. Much like a battery losing its charge, each time there is a new response to an old

trigger the cravings will begin to subside. In time, former cravings become nothing more

than thoughts.

Adapted from:

Health Canada www.hc-sc.gc.ca/hc-pubs/tobac-tabac (2010)

Why Quit www.whyquit.com (2009)

McEwen, A. et al. (2006). Manual of smoking cessation. A guide for counsellors and practitioners.

Blackwell Publishing: USA.

Benefits of Quitting: (read aloud with the group)

Enough of the bad news, now for the good news. Quitting smoking is the most

important health decision that most people can make. By quitting smoking, you will add

years to your life. You will also increase the quality of your life. You will breathe easier,

walk further, exercise more, taste food and smell better. You will feel and be healthier as

a non-smoker than you would have been if you kept smoking. Your risks of bladder

cancer, cervical cancer, cancer of the larynx, and peripheral artery disease are reduced by

quitting smoking. You will see that your health quickly starts to improve once you quit

and the earlier you quit, the greater the chance that you will overcome the risks caused by

smoking. But quitting smoking improves your health at any age.

In 1990, the United States Surgeon General published a report called “The Health

Benefits of Smoking Cessation.” That report was 928 pages long!

20 minutes after your last cigarette

Most of the nicotine has left your brain. Your blood pressure and pulse rate goes back to

normal.

8 hours after your last cigarette

The level of carbon monoxide in your blood has decreased to normal. The level of

oxygen rises to normal.

24 hours after your last cigarette

Your risk of having a heart attack begins to go down.

2 days after quitting

You can taste and smell things better.

2 weeks after quitting

Your lungs are working better. You have better blood circulation.

1 month after quitting

You cough less and have less shortness of breath. You breathe better and are not as tired.

1 year after quitting

http://www.hc-sc.gc.ca/

http://www.whyquit.com/


Your risk of heart disease has been cut in half.

5 years after quitting

Your risk of dying of lung cancer has been cut in half. Your risk of oral cancers has also

been cut in half.

5-15 years after quitting

Your risk of stroke is about the same as someone who never smoked.


Your risk of lung cancer is nearly the same as someone who never smoked. Your risk of

pancreatic cancer has also been reduced.


Your risk of heart disease is as low as if you never smoked.

Health Canada www.hc-sc.gc.ca/hc-pubs/tobac-tabac (2010)

Canadian Mental Health Association (2005). Breathing Easy Workbook. Health Canada: Canada.



Week 5: Managing our Emotions - Stress

Purpose: To start to introduce coping/lifeskills that will help clients find balance and

sustain quitting.

Opening round:

• How has the process been over the past week? • Brief meditation or relaxation exercise • Explain to the group that the following weeks will start to focus on lifestyle change and

finding balance so that they have the skills in place to stay quit


• Overview of what “balance” looks like • Brainstorm experiences of stress • Explaining relationship between stress and smoking • Review coping strategies for stress

Closing round:

• Name a smoking related goal for the week and one self-care option


Introduction: What is Balance?

We are in a constant state of growth as individuals. As we start to focus on one particular

change, such as quitting smoking, we may notice that we are prompted to make other

changes as well. Some of these changes may be by choice and some out of necessity. It

is important to become observant of what is happening in our lives when we feel good

and what is happening when we feel overwhelmed, negative, or depressed. This interplay

of things that give us energy and things that deplete our energy informs us about healthy

balance. In this program we explore four dimensions of health - emotional, social,

physical, and psychological.

Clients will find that as they quit smoking social, emotional, and physical voids emerge

that used to be filled by cigarettes. As well, their needs and coping will be in constant

flux. If needs, coping and the absence of smoking are not addressed clients often find

themselves discouraged, disappointed, and struggling to stay quit. It is often argued that

quitting smoking is easy; staying quit is the hard part.

The participant manuals offer two different exercises for exploring balance. Doing one

of the exercises as a group can be helpful in the discussion of balance. If time does not

permit this brainstorm then introduce the exercises for journaling over the next week.

Option 1: What are you doing to fulfil each of these dimensions of health? What area do you feel

strongest in? What area do you feel you need to work on? Do you feel balanced? If it is

helpful choose a different colour of pen and add activities that you would like to have in

your life to create more balance.

Physical What are you doing to support your physical health?

What are you doing to create a healthy environment?

ie. Exercise, no smoking in the house, eating well,

walking, no smoking in the car, clean house

Psychological What are you doing to build your self-esteem?

How are you taking care of your mental wellbeing?

ie. Taking a class, counselling, self-care, exercise,

reading, learning something new, medications


Spiritual Spirituality is the thoughts, feelings, and behaviours that provide our sense of

connection to the world around us.

Emotion What are you doing to take care of your feelings and

accept your feelings?

ie. Accessing support, exercise, meditation,

planning, self-care, crying and laughing

Social What are you doing to build or strengthen your

relationship with others (work, community, family)?

ie. Setting boundaries, not smoking with family,

connecting with others, joining a group

Option 2: This exercise can be used as a daily or weekly reflection about our physical, emotional,

social, psychological, and spiritual health. Simply ask yourself: What am I doing that is

giving energy, fuelling my motivation, or inspiring me? And, what is happening in my

life or what am I doing that is taking energy away from me? We cannot avoid all stress

and negative circumstances. When you observe your chart, do feel that you have balance

between self-care and responsibilities? Do your positive coping, activities, and self-care

outweigh what drains you?

What gives you energy? What is draining your energy?

Managing Emotions:

Exercise 1: Brainstorm about Stress

Ask: What do you experience as stress in your life?


Write the answers on a flipchart. Groups frequently focus on negative life events as

stressful, if it does not come up, prompt the group about stressful events that are often

perceived as happy (parenting, childbirth, wedding etc.).

Summarize with a discussion about types of stress and the role of stress in our lives.

Stress is an information system that we all experience. It can be in small daily hassles or

major events. Healthy stress activates our nervous system and motivates us to meet our

basic needs and to make changes when necessary. Stress becomes unhealthy when our

system is overwhelmed. We may feel vulnerable, isolated, and struggle with accessing

our coping skills.

The relationship between smoking and stress is both physical and psychological.

Nicotine causes the brain to release chemicals called neurotransmitters. Some of these

chemicals, such as beta-endorphin and norepinephrine can cause a person to feel better,

but only for a short period of time. Because nicotine is a stimulant it serves as a quick

pick-me-up. Unfortunately, that pick-me-up is temporary and physical signs of stress

may increase as a person starts to experience withdrawal.

Emotionally, smokers often use the act of smoking as a ‘time out’ from thinking about or

dealing with stress. Like any activity, smoking can distract a person from his or her

troubles. Taking time to gather our thoughts is a useful self-care tool, but using smoking

as the excuse will not help to resolve whatever the stress is.

People who have significant stress in their lives tend to have a harder time quitting

smoking. This is also true of people who are prone to negative moods, such as sadness

and anxiety. We also know that when ex-smokers start smoking again, they often have

the first cigarette in response to stress or moods. It is essential that smokers develop

awareness about stress in their lives and develop coping skills to deal with it.

Exercise 2: Tools for Managing Stress

Ask the group to follow along in their manuals and review options for managing stress.

This can be done by the facilitator or have group members read aloud.

Strategy 1: Avoid unnecessary stress Learn to recognize stress in your life and you may be surprised by the small changes that

you can make. Start a stress journal if that is helpful

• learn to say ‘no’ • avoid people who stress you out • take control of your environment - ie. if the evening news makes you anxious then stop

watching it • pare down your to-do lists - differentiate between ‘shoulds’ and ‘musts’ • avoid ‘hot button’ topics - if talking about religion or politics gets your blood boiling

then stop those conversations. If you repeatedly argue about the same topics with the

same people then make the decision to excuse yourself.


Strategy 2: Alter the situation If you can’t avoid a situation, try to alter it.

• express your feelings instead of bottling them up • be willing to compromise • be more assertive • manage your time better - stop procrastinating, set priorities and stick to them

Strategy 3: Adapt to the stressor If you can’t change the stressor, change yourself. You can regain a sense of control by

changing your expectations or attitude.

• reframe problems • look at the big picture - gain some perspective, “is this really a big deal or will it pass?” • adjust your standards • focus on the positive

Strategy 4: Accept the things you cannot change Stress is an unavoidable experience in life.

• don’t try to control the uncontrollable • look for the upside • share your feelings • learn to forgive - we are imperfect people

Strategy 5: Make time for fun and relaxation Take charge of stress reduction and nurturing yourself

• set aside relaxation time - have a safe space, exercise, deep breathing • connect with others - you are not alone, utilize support systems • do something you enjoy every day • laugh - this includes being able to laugh at yourself

Strategy 6: Adopt a healthy lifestyle It is important to keep energy moving in our bodies and strengthen our health.

• exercise regularly • eat healthy • reduce caffeine • avoid alcohol and drugs • get enough sleep Adapted from:

The Help Guide www.helpguide.org/mental/stress_management_relief_coping.htm (2009)

http://www.helpguide.org/mental/stress_management_relief_coping.htm


Ask the group if they have any additional feedback or ideas about stress management. If

time is limited, inform the group that they have a stress management plan worksheet in

their manual that they can do for homework.

Optional Exercise: Personal Stress Management Plan

We know that stress happens whether we like it or not. We can learn to manage our

stress better by setting up a plan. Stress planning can be achieved in 2 ways. The first is

anticipatory. This is when we identify in advance the situations that are stressful to us

and set up coping strategies that can help to reduce or alter the stress we might

experience. The second strategy is reflection. Like journaling we can use hindsight to

acknowledge stress and assess what worked and didn’t work for managing it. From this

knowledge we can set a plan for better management in the future.

The following questions can support you in your plan:

What is the stressful situation?

Is this situation something I can change or do I need to accept it?

If I can change it, is there any small thing I can change/do right now to reduce this

stress?

Who can I turn to for support? And/or what types of support would be helpful to

get through this?

What coping skills have worked for me in the past that might be helpful now?

What are some new coping skills I might be willing to try?


Week 6: Healthy Living

Purpose: To support the group in exploring options for improving their health through

diet and exercise, and to explain the relationship between quitting smoking and weight

gain.

Opening Round:

• How has the process been over the last week • brief relaxation exercise • explain to the group what you will be talking about this week

Exercises to Complete:

• Discuss the relationship between quitting smoking and weight gain • provide a copy of Canada Food Guide if you have any available • Brainstorm simple ways to increase daily physical activity

Closing Round:

• Name one self-care activity you will do this week and one quit smoking goal for the

week


Exercise 1: Quitting Smoking and Weight Gain

For many people, particularly women, there is a fear that quitting smoking will result in

weight gain. The average person may gain 5-7 pounds when quitting smoking. This

happens for a variety of reasons (go into details later in the session). Fortunately, most

people lose this weight within the first 6-12 months of being smoke free.

Remember: This weight gain is small compared to the health benefits of quitting.

Smoking does much more harm to your health and to your looks than does the added

weight. The stress on your heart of smoking one pack of cigarettes per day is equal to

being 90 pounds overweight! Quitting smoking decreases your risks of lung cancer, other

cancers, heart attack, stroke, and lung problems. For most people, smoking is far more

dangerous to your health than is extra weight.

Ask the group to turn to the page in their manual that talks about quitting smoking and

weight gain (I Quit Smoking…Now I Need to Manage my Weight). Read through this

information with them. When done ask each person in the group to commit to one

healthy diet choice for the week - it may be buying fruit or vegetables, changing snack

items, eating regular meals, cooking at home etc.

I Quit Smoking….Now I Need to Manage my Weight Information compiled by Ingrid Vurduyn, RD, community and addictions nutritionist VCH

Why does weight gain happen after quitting smoking?

· When you smoke, the nicotine (which is an appetite suppressant) makes you less

hungry

· Nicotine increases your metabolic rate above normal (burns more calories)

· Smoking involves more than 400 hand to mouth movements in a day- it will take

some time to stop this reflex

When you quit smoking….

· Your metabolic rate returns to normal. This means your calorie needs go down

by 100-200 calories per day


· Your taste buds can start to taste again and flavourful food is wonderful

· You may still have the ‘hand to mouth’ habit only now it is food in your hand

Snacks under 100 calories:

· 1 cup any fruit

· ½ cup low fat yogurt

· 1 boiled egg

· 1 cup most vegetables

· Pickles

· 5 melba toast or saltines

· Mini bag of popcorn

· ½ cup cottage cheese

· ½ cup of milk

What can you do:

· Eat healthy meals and lower calorie snacks at regular intervals (3 hours)

· Get enough vitamin B and C (see list below)

· Be aware that you may crave caffeine and sugar which can add extra calories if

you use sugar or cream

· Delay or distract to get through cravings

· Be active – it helps to control you weight and helps move secretions. After

quitting smoking you may initially cough more as your cilia are recovering from

tar build up

· Be mindful of your eating – eat slowly, pick healthy and satisfying foods, put

your fork down between bites

· Don’t dwell too much on your weight – the benefits of smoking mean you will

have more energy for active living

Foods rich in Vitamin C:

Whole Food Sources Serving Vitamin C (mg)

Sweet red pepper ½ cup, raw 141

Strawberries 1 cup 82

Orange 1 medium 70

Brussels sprouts ½ cup 68

Broccoli, cooked ½ cup 58

Collard greens, cooked ½ cup 44

Grapefruit ½ medium 44

Cantaloupe ¼ medium 32

Cabbage, cooked ½ cup 24

Tomato 1 medium 23


Aim for at least 100mg vitamin C daily. Choose fruits and vegetables as your source

because they contain other beneficial substances not found in supplements (like

phytochemicals). Too much vitamin C (>1000mg/d) can cause nausea and kidney stones.

Foods rich in B Vitamins:

There are 6 B vitamins in various foods. Most breakfast cereals are fortified with B

vitamins. Here are some vitamin B ‘best bets’ – liver, beef, tuna, oats, turkey, brazil nuts,

bananas, avocados, legumes (beans, lentils, peas).

Exercise 2: Physical Activity and Quitting Smoking

Getting regular exercise is one of the best ways to offset potential weight gain. Physical

activity has other benefits as well. Exercise will help your body recover faster from the

negative effects of smoking. It will also give you more energy and help to fill some of

the time gaps left behind when quitting smoking.

Physical activity does not mean that you have to run a marathon. It can consist of simple

everyday changes that introduce movement, stretching, or resistance activities into our

lives. For example, taking the stairs instead of the elevator. Ask the group to

brainstorm simple activities that work for them or that they would be willing to try.

After the brainstorm suggest that clients reflect back on their calendars from week 3 and

integrate activities into their plan.

Possible suggestions in the brainstorm:

• playing with your kids • get off the bus a couple of stops early and walk • take a walk anywhere • ride a bike • stretch in the morning when you wake up • clean your house • garden • join a sports team Adapted from: Canadian Cancer Society (2009). For smokers who want to quit. Canadian Cancer Society:

Canada.


Week 7: Staying Positive and Supported

Purpose: To help the group identify self-talk and learn to use it as positive

reinforcement. To explore individual support systems and set up a plan to maintain

healthy supports.

Opening Round:

• how has the process been over the past week • offer a brief positive visualization. Ask the group to imagine themselves as a non-

smoker - integrate questions such as what are you wearing, what are you doing, who are

you with, how are you feeling...as they build their self-image (see appendix for detailed

visualizations) • remind the group that it is the second to last week of the closed group


• understanding self-talk • how to reframe our thinking • personal bill of rights (optional, time permitting) • defining our needs and expectations for social support

Closing Round:

• Name one self-care goal for the week and one smoking-related goal for the week. • At this point you may have several people with some quit time under their belt,

encourage them to still set goals that relate to changing their behaviours.


Exercise 1: Understanding Self-talk Self-talk is the little or sometimes powerful voice we hear in our heads. This voice is

always hard at work and plays a significant role in influencing our behaviours and

emotions. When this voice is positive we may notice an improvement in our mood,

improved self-esteem, and increased confidence. It motivates us to continue moving

forward in making changes. When our self-talk is negative, the opposite is true. We may

notice volatile emotions, sadness, anger, and stress. We may be more likely to give in to

cravings or temptations or to simply feel like throwing in the towel.

For many people with a history of addiction, negative self-talk is also associated with the

addictive voice. This is often experienced as a battle in our heads between a voice that

wants to relieve discomfort, or seek reward at all costs and a voice that is often perceived

as ‘the voice of reason’. In this situation, it is the voice of reason that we want to listen

to, and strengthen.

It would be wonderful if we all lived in a perfect world, and thought perfect thoughts, and

behaved in perfect ways. This is true for no one. Instead, how we see ourselves and how

we view the world is coloured by our personalities (some people are naturally more

upbeat than others), and our life experiences. When we identify negative self-talk, we

can usually associate it with distorted thinking or beliefs that have been learned over

time. The more we challenge unhelpful thinking, the more we start to believe that we can

get through anything.

Some examples of negative/distorted thinking that can be discussed with the group.

Clients can follow along in the manuals or be instructed to review their manuals at a

home.

Catastrophizing - you believe that what has happened or will happen is so terrible that

you won’t be able to stand it. “It would be horrible if I had a cigarette.”


Overgeneralizing - you perceive a global pattern of negatives based on a single incident

“I gave in to a cigarette. I will never be able to quit”

All-or-nothing thinking - “nobody supports me” or “I had a smoke so I have failed”

Shoulds - interpreting events based on how you believe things should be rather than

simply focusing on what is. “I should have quit by now” “I should feel better” “I should

be at 2 cigarettes and I am not.”

Personalizing - you put a disproportionate amount of blame on yourself. “I haven’t quit

yet because I am not strong enough” or “I haven’t quit yet because I am not good at

making change”

What if? - constantly thinking of future possibilities/events and are never satisfied with

any of the answers. “what if the patch doesn’t work” “What if I have relapse and smoke

again...”

Emotional Reasoning - letting your feelings guide your interpretation of reality, “I am

stressed I need a smoke”

Adapted from: Leahy, R. (2003). Cognitive therapy techniques. Guildford Press:New York.

After explaining what negative self-talk looks like, ask the group to come up with a few

of the negative phrases that happen for them in relation to quitting smoking. If the group

struggles with identifying their self-talk prompt them with 2 or 3 common negative

statements that people tell themselves when trying to quit. Examples could be, “I am too

stressed I need a smoke” or “One cigarette won’t hurt” or “I should have quit by now”.

Write these on a flipchart and work with the group to come up with positive self-talk

counter phrases. Encourage them to use the worksheet in their manual to come up with

more positive phrases as a journaling exercise.

Exercise 2 (optional): Personal Bill of Rights This exercise can be used as an expansion on positive self-talk. If there are time

constraints this exercise can be introduced and then encouraged as a homework/

journaling option.

As talked about already, our beliefs and how we see the world are influenced by life

experience. Everyone experiences challenges, bad events, bad relationships, and overall

struggles (of course some people have more traumas than others). We can easily end up

focussing on these negative experiences or acquire a belief that we are bad people, that

we deserve bad things, or that we are helpless/hopeless to change things. This is not true.

The manner in which we see and engage in the world is a choice. When we are invested

in making a change it is important to acknowledge and reinforce our values and abilities,

as well as, what we deserve in our lives.


A personal bill of rights is about setting the standards for how you want to live your life,

much like the mission statement of an organisation. Phrases should start with:

I deserve...

I have the right...

I am able...

I will....

I can...

Brainstorm with the group about positive statements that they would want to see on

their lists. Examples might be: I deserve clean air, I will live smoke free, I have the

right to a healthy home, I have the right to a healthy body, I deserve supportive people in

my life, etc. When the brainstorm is complete have the group right down their own lists

on the worksheet in their manual.

Exercise 3: The Role of Social Support Social support plays an essential role in our success at change. It can help us to maintain

a positive attitude, can get us through a craving, and it can provide encouragement

through the difficult times. When we approach quitting smoking it is important that we

take a close look at what we find supportive and who we can get support from.

Everyone’s idea of support may be a little bit different.

Depending on time this exercise can be a discussion about helpful and unhelpful support

with a brainstorm on the following three questions and individual plans. Or the facilitator

can read through the information with the group and suggest that it get completed as a

journaling exercise.

Part 1:

Before we solicit support from others, we need to know what we find helpful and

unhelpful behaviours from others. Ask yourself the following questions:

Describe the behaviours of others that are helpful or supportive.

Describe the behaviours of others that interfere with your efforts.

What behaviours do I feel comfortable asking others to do?


Part 2:

Once we know what we want, we can look to the support that is available. Support can

be accessed from 3 primary areas - family or close friends, the community, or

professional support systems. It is helpful to have a variety of options that can be drawn

on.

Ask the group to use the following chart to identify the types of support available in their

lives (family, friend, community, professional) and how these supports can helpful. Ask

that they observe the needs that are not being met and use it as an opportunity to explore

new resources. Suggest that they talk to other quitters to find out what worked for them.

Name Type of Support How this support can help you

ie. Jim Partner ask him to quit with me, ask him not to smoke in front of me, don’t offer me smokes

Adapted from:

Abrams, D. et al. (2007). The tobacco dependence treatment handbook. Guildford Press: NY.

Canadian Mental Health Association (2005). Breathing easy workbook. Canadian Mental Health

Association: Canada.


Week 8: Staying Quit/Relapse Prevention

Purpose: to support the group in creating their own relapse prevention strategies. To

provide an opportunity to have closure with the group.

Opening round:

• how has the process been over the past week • relaxation exercise • explain that it is the last day, outline what they are expected to do for aftercare, ask if

there are any remaining questions or concerns


• discuss a slip and relapse - options for what to do • explore relapse prevention planning • distribute the 8-week client satisfaction survey

Closing round:

• describe one new tool/skill that you are taking away from this group


Exercise 1: Understanding a Slip Read with the group:

There is a difference between a slip and a relapse. A slip is when a person has an

occasional cigarette or two. This person may find themselves feeling guilty or thinking

about the reasons why they stopped with each smoke. A slip is often done in secret. A

relapse, on the other hand, is when a person starts to smoke regularly with at least half the

number of daily cigarettes as before they quit. It is a return to smoking with friends and

in stressful situations. A relapse also has a higher likelihood of building nicotine

dependence again.

Unfortunately, nine out of ten ex-smokers who have a cigarette after

quitting later return to regular smoking. You must do everything you

can to avoid that first cigarette.

What should you do if you find yourself smoking:

• stop right away and throw out the cigarettes • don’t allow yourself to feel defeated, tell yourself, “This is just a slip. Everything

is not lost.” • tell yourself “this is my last cigarette. I am smoke free” • commit to quitting again right then and there. • learn from the experience. Ask yourself, “what was the trigger”, review the

PHALT chart, is there something you need to avoid in the future • use your coping skills • minimize negative thoughts, remind yourself that this is all part of the process • seek support

We discuss a slip not to give permission for it to happen but to encourage you to prepare

in case it you find yourself at risk. If you do have a slip staying with the quitting process

is far more likely if you have a plan in place to get back on track after the first cigarette or

puff.

Don’t write yourself off as a failure if you have a cigarette after quitting. It makes more

sense to use this experience to review all you have learned and to get yourself back in the


process. In being prepared for a slip it is important to think about what you should do in

various situations. You need to have your coping skills ready to help you put down that

cigarette, recognize and deal with a risky situation. You also need your coping skills to

prevent you from lighting another one.

We can compare preparing for a slip to preparing for a fire. If you have children, you

may have taken the time to talk to them about what to do in case of a fire. They should

know ways to get out. They should know to stop, drop and roll if their clothes catch fire.

And so on. They should also know that fire is very serious. Just because they know how

to respond to it does not mean that it is okay to play with matches. They still need to

prevent fires at all costs. Having a cigarette is like playing with fire. Avoid smoking at

all costs, but know what to do just in case you have a cigarette.

Exercise 2: Creating your Relapse Prevention Plan

It is clear that the best way to stay quit is to avoid situations or learn to cope with

situations that are high risk. Whether you have completely quit at this point or you are

simply practising getting to that point, you should be aware of situations, feelings, and

people that are a challenge for you.

Instruct the group to use the following chart to identify at least 2 or 3 situations that are

high risk. Offer a few minutes to complete the exercise and then have the group share

some examples. Use a flipchart or white board to share the plans.

high risk

situation/feeling

who will you

seek support

from

how can you

distract yourself

positive self-talk

you can use

any other

options

available


Suggest that the group continue working on this chart at home. They can return to their

triggers worksheets from week 2 for ideas if needed.

Handout the 8-week Satisfaction Survey and collect it before closing round.

Appendix: Meditation Exercises

Meditation offers many benefits. We know that the acute experience of a cravings last

only 3 minutes. Basic relaxation can help individuals get through such a craving. We

also know that focused relaxation can help to ground us, regulate our emotions, bring

focus, and support ongoing motivation. The following meditations are designed as 3-7

minute exercises.

Option 1: Body Scan

· Sit comfortably in a chair with feet flat on the ground. Start to notice your

breathing. Imagine that your lungs are a balloon. Breathe in and inflate the

balloon. Exhale slowly until the balloon feels empty.

· Starting with your feet and moving up, physically observe your body. Are there

any areas of tension? When you notice tension take a moment to stretch it out or

squeeze and release the muscle. When you have completed your scan, notice that

you may feel heavier in your chair, that your body is completely relaxed.

· Observe your thoughts and emotions. How are you feeling right now? Are you

able to let go of the stressors in the day and simply focus on this moment?

· Come back to your breathing. Notice the rhythm of breathing in and out. Come

back to room when you feel ready.

Option 2: Visualization




· Imagine yourself as a non-smoker. You are celebrating freeing yourself from the

ball and chain of cigarettes. Your days are no longer scheduled around finding

the next opportunity to smoke. You can enjoy sitting through a meal without

leaving the table. You can sit through a movie without having to pause it or

leaving the theatre. You can enjoy time with non-smoking friends and no longer

feel ashamed of your nasty habit. You no longer have to stand outside in the rain


or snow to feed your addiction. You feel confident, healthy, and ready to take on

a new life.

· Come back to your breathing. Observe your feelings and tell yourself “I am

going to quit smoking” “I deserve to be healthy and happy”. Return to the room

when you are ready.

Option 3: Visualization




· Imagine your quit date and quickly move past it into your first days and weeks as

a non-smoker. Create a mental picture of the ways that you will benefit from this

change. Notice your surroundings? Is your home cleaner are you sitting inside?

Perhaps you are enjoying some exercise and fresh air. How do you feel? Are

your clothes fresher, your teeth whiter? Are you breathing better and sleeping

better? Notice the lightness and freedom you might feel, the increase in self-

esteem, and the connection with others. You feel proud of yourself. How does

food taste? Do you have extra money to enjoy new activities?

· When you have played out your mental movie come back to your breathing.

Congratulate yourself for taking on this journey. Tell yourself, “I will be a non-

smoker” or “I am proud to be a non-smoker”. Return to the room and stretch if

you need to. Adapted from:

SelfGrowth.com – The Online Self-improvement Centre:

http://www.selfgrowth.com/articles/Quit_Smoking_Techniques_7_Steps_with_Creative_Visualization

(2011)

HealthMad:

http://healthmad.com/alternative/how-to-quit-smoking-with-meditation (2011)

Canadian Mental Health Association (2005). Breathing easy workbook. Canadian Mental Health

Association: Canada.


http://healthmad.com/alternative/how-to-quit-smoking-with-meditation


References

Abrams, D. et al. (2007). The tobacco dependence treatment handbook. Guildford Press:

NY.

CAMH TEACH Project


Canadian Cancer Society (2009). For smokers who want to quit. Canadian Cancer

Society: Canada.

Canadian Mental Health Association (2005). Breathing easy workbook. Health Canada:

Canada.

Health Canada http:// www.hc-sc.gc.ca/hc-pubs/tobac-tabac (2010)

HealthMad

http://healthmad.com/alternative/how-to-quit-smoking-with-meditation (2011)

Help Guide http://www.helpguide.org/mental/stress_management_relief_coping.htm

(2009)

Leahy, R. (2003). Cognitive therapy techniques. Guildford Press:New York.

McEwen, A. et al. (2006). Manual of smoking cessation. A guide for counsellors and

practitioners. Blackwell Publishing: USA.

Quit Now http://www.quitnow.ca (2010)

SelfGrowth.com – The Online Self-improvement Centre

http://www.selfgrowth.com/articles/

Quit_Smoking_Techniques_7_Steps_with_Creative_Visualization (2011)



http://healthmad.com/alternative/how-to-quit-smoking-with-meditation

http://www.helpguide.org/mental/stress_management_relief_coping.htm

http://www.quitnow.ca/




The Tobacco Research and Intervention Program at the H. Lee Moffitt Cancer Centre and

Research Institute at the University of South Florida. http://www.moffitt.org (2010)

Why Quit http://www.whyquit.com (2009)

http://www.moffitt.org/

http://www.whyquit.com/

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